I grew up in Macomb County, Michigan. In many ways, it’s the idyllic Midwestern community: charming, welcoming, buoyed by the automotive industry, and full of apple orchards and classic car shows. But despite being in the upper third of the state in socioeconomic status, it’s in the bottom third in health outcomes. And it leads the state in number of opioid deaths, second only to Wayne County, which includes Detroit.
Many of my friends, family, and neighbors have chronic health conditions, and some of them struggle to afford health care. And yet, despite the Democratic Party’s emphasis on affordable care, many of the same people voted for President Trump in 2016. Between the 2008 and 2016 presidential elections, Macomb County swung 20 points toward Republicans.
In 2016, the physician-sociologist Jonathan Metzl interviewed white men in communities not unlike mine, all across the country. In Tennessee, he met Trevor. “Ain’t no way I would ever support Obamacare or sign up for it,” said the 41-year-old white man. “I would rather die.”
Yet Trevor was dying. His liver was failing due to chronic substance use and hepatitis C. Because he was uninsured and low-income, the medical care that could protect his liver and cure his hepatitis C eluded him. Under the Affordable Care Act, states had the option to expand Medicaid coverage to more low-income Americans. But Tennessee hadn’t.
When Metzl asked Trevor why he felt this way, the dying man replied, “We don’t need any more government in our lives. And in any case, no way I want my tax dollars paying for Mexicans or welfare queens.”
If you spent a day in Macomb County, I’m sure you’d meet plenty of people just like Trevor: low-income, uninsured, white, and stringently opposed to the expansion of Medicaid or any government “interference” in health care, despite being clearly positioned to benefit from it. The details of their motivation are often opaque and rooted in complex cultural, economic, and political histories. But one aspect of their decision-making is perfectly clear: Medicine doesn’t exist in a vacuum.
Health is one of the defining political and economic issues of modern America. We spend 18 of every 100 dollars on health care; as voters, we’re captivated by the torturous details of health insurance reform. It’s all for good reason: Health status and medical care interact intimately with our experiences and societal structures. Social, economic, and political movements shape the health of individuals.
But what about the opposite direction? That is, what impact do health and medical care have on the world outside the hospital?
An easy example is disability. The proper functioning of our muscles, bones, and minds allows us to engage with the world. For example, hip replacements are performed on adults of any age, even into their 90s. This is despite the manifold risks of surgery. So why do them? Because they dramatically improve quality of life. My grandmother recently had a hip replacement in her mid-80s, and her new self has reengaged with the world. Able to walk with greater ease, she roams her senior living facility, cheerily plays cards with neighbors, and ventures out to worship, shop, and dine. (Or at least she did before COVID-19.)
The research is clear. Hip replacements improve the physical and mental health of recipients and may even extend their lives. More quantitatively elusive but nevertheless important are their social benefits.
Let’s try a deeper cut: Teeth. We as future physicians — and Americans in general — often overlook teeth, yet they take center stage in our lives: eating, speaking, smiling. Tools of expression and symbols of status, they dominate our interactions. We couldn’t live without them.
Teeth can also insidiously impede our worldly pursuits, setting us onto lower economic trajectories. In her book Teeth, the journalist Mary Otto tells the story of Aida Basnight. Aida used to work as a secretary in Chicago. Starting in her 30s, however, she experienced one oral infection after another. Early on, she lost her molars, then many others. In her 50s, she lost her job and home and began sleeping in a park in D.C. Despite her wit and work ethic, no one would hire Aida.
She recalls her mother saying, “Nobody’s gonna hire you with that bunch of gaps in your teeth.” Aida added, “I always feel self-conscious about them in the interviews. I can’t smile because I’ve got no teeth.” Now, Aida lives on the streets of D.C., selling a newspaper produced by the city’s homeless. She is “careful to smile with her mouth closed.”
Aida’s experience is not unique. In a 2015 survey by the American Dental Association, nearly 4 in 10 low-income Americans felt embarrassed to smile because of the condition of their teeth. About the same number believed that it inhibited their ability to interview for a job.
While teeth are not the sole reason that many Americans struggle to find work, they contribute to the economic struggles of many. About 100 million hours of productivity are lost each year because of oral health problems, and the least privileged among us shoulder the greatest burden. So profound is the impact of health on how we lead our lives.
Let’s keep going: Our health even appears to shape our political orientation. A burgeoning subfield of public health research suggests that health status predicts whom we vote for. A number of recently published articles (including a forthcoming one by yours truly) have shown that people with worse health are more likely to vote for Trump, Brexit, and populist parties across the European continent.
The effect isn’t small: When we control for socioeconomic and cultural factors, health exerts a greater effect on voting than education and how comfortable we feel about our paychecks. This finding is especially surprising since many populist parties have threatened to reduce access to affordable medical care. It suggests that health strikes at a deep vulnerability that radically resets our political mindset.
Which brings us back to Trevor. His decision to vote Republican — despite the refusal of Tennessee Republicans to expand Medicaid — reflects the rich interplay between our health and social context. This interplay is messy and begs for more explanation, but it makes one thing clear: no medical or public health decision is socially neutral. Every drug, surgery, and behavioral therapy that we provide is as much a medical intervention as a social, economic, and political one. This conclusion raises an important question: What is the role of (future) physicians in society? And should we be paralyzed by its expanse?
As a guiding principle, we must treat all patients with dignity. For example, we absolutely should not strip health resources away from low-income people if we want them to vote a certain way. But we must also recognize that our work intervenes broadly on our patients’ lives, unmistakably altering the memories that they make, the way they earn a dignified living, and what they envision as a just society.
We should be especially careful with decisions about the distribution of health care resources within our society. For this reason, I believe that we as (future) physicians should insert ourselves into more social and political conversations than we do. We have a lot to say.
But at the very least, we should think about our impact on people like Trevor. Even though he sees us for only a few hours each year, we continue to have a presence in his life during all the other hours, too.
Nolan Kavanagh is an MS1 at the Perelman School of Medicine. Nolan can be reached by email at [email protected].
